Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10169 Form B _ Bidding Form	Form and Instruction	Unchanged	Available
Form CMS-10169 Form A	Form and Instruction	Unchanged	Available
Form CMS-10169 Change of Ownership - Purchaser Form - 30-day notice	Form and Instruction	Unchanged	Available
Form CMS-10169 Change of Ownership - Contract Supplier Notificaiton Form - 60-day Notice	Form and Instruction	Unchanged	Available
Form CMS-10169 Contract Suppliers Disclosure of Subcontractors	Form and Instruction	Unchanged	Available
Form CMS-10169 Beneficiary Survey (Spanish Language Version)	Form and Instruction	Unchanged	Repair queued
Form CMS-10169 Beneficiary Survey (English Language Version)	Form and Instruction	Unchanged	Available
Form CMS-10169 Quarterly Report	Form and Instruction	Modified	Available
CMS-10169 - Revised Supporting Statement part A PRA_FINAL (August 2015).pdf	Supporting Statement A	Uploaded 2015-08-05	Available
DESCRIPTION OF FORM C NON-SUBSTANTIVE CHANGE_Final (August 2015).pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2015-08-05	Available
CMS-10169 (0938-1016).DESCRIPTION OF NON-SUBSTANTIVE CHANGE - FINAL (2).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-11-03	Available
508_Crosswalk for Form B PRA 6-30-14.pdf	Supplementary Document	Uploaded 2014-07-07	Available
508_Crosswalk for Form A PRA 6-30-14.pdf	Supplementary Document	Uploaded 2014-07-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212257	Bidding Form (Form B)	Form and Instruction	Unchanged	Form B _ Bidding Form
212256	Application for DMEPOS Competitve Bidding Program (Form A)	Form and Instruction	Unchanged	Form A
206873	Change of Ownership (CHOW) - Purchaser Form	Form and Instruction	Unchanged	Change of Ownership - Purchaser Form - 30-day notice
206872	Change of Ownership (CHOW) Contract Supplier Notification Form	Form and Instruction	Unchanged	Change of Ownership - Contract Supplier Notificaiton Form - 60-day Notice
203541	Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure	Form and Instruction	Unchanged	Contract Suppliers Disclosure of Subcontractors
203540	Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	Form and Instruction	Unchanged	Beneficiary Survey (Spanish Language Version)
203540	Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	Form and Instruction	Unchanged	Beneficiary Survey (English Language Version)
203539	Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C)	Form and Instruction	Modified	Quarterly Report

ICR Details

OMB Control No: 0938-1016	ICR Reference No: 201508-0938-005
Status: Historical Active	Previous ICR Reference No: 201411-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: 19556
Title: Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/08/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/05/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	09/30/2017	09/30/2017
Responses	36,997	0	39,455
Time Burden (Hours)	234,194	0	235,014
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare DMEPOS Competitive Bidding Program was established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 ("Medicare Modernization Act" or "MMA"). Section 302 of the MMA amended Section 1847 of the Social Security Act to establish the competitive acquisition program and define program requirements. The most recent approval for this information collection request (ICR) was issued by OMB on June 10, 2013. That ICR included the estimated burden to collect the information in bidding Forms A and B for the Round 1 Recompete. We are now seeking approval to collect the information in Forms A and B for competitions that will occur before 2017.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 302(b)(1) Name of Law: Payment for durable medical equipment; competitive acquisition of certain items and services
   PL: Pub.L. 110 - 275 154 Name of Law: Delay in and Reform of Medicare DMEPOS Competitive Acquisition Program
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 275 154 Name of Law: Delay in and Reform of Medicare DMEPOS Competitive Acquisition Program

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 21932	04/18/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 38033	07/03/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Application for DMEPOS Competitve Bidding Program (Form A)	CMS-10169	Form A
Bidding Form (Form B)	CMS-10169	Form B _ Bidding Form
Change of Ownership (CHOW) - Purchaser Form	CMS-10169	Change of Ownership - Purchaser Form - 30-day notice
Change of Ownership (CHOW) Contract Supplier Notification Form	CMS-10169	Change of Ownership - Contract Supplier Notificaiton Form - 60-day Notice
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C)	CMS-10169	Quarterly Report
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure	CMS-10169	Contract Suppliers Disclosure of Subcontractors
Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	CMS-10169, CMS-10169	Beneficiary Survey (English Language Version) ,   Beneficiary Survey (Spanish Language Version)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	36,997	39,455	0	0	-2,458	0
Annual Time Burden (Hours)	234,194	235,014	0	0	-820	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: In this non-substantive change request, we have adjusted the burden downward as a result of adjusting the reporting requirement for Form C from quarterly (4 times per year) to semi-annually (2 times per year). As a result of the adjustment, the overall number of responses and burden hours have decreased by 2,458 and 820 hours, respectively.

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Annual Cost to Federal Government: $2,310,864

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/05/2015

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